The undersigned

for

declares that the following mentioned goods shipped via

on the date of

consigned to

are the products of the United States of America.

MARKS AND NUMBERS	NO.OF PKGS. BOXES OR CASES	WEIGHT IN KILOS GROSS NET		COMPLETE AND ACCURATE DESCRIPTION OF GOODS

These commodities, technology or software were exported from the Unites States in accordance with the Export Administration Regulations. Diversion contrary to United States law prohibited.

Sworn to before me this day of

Dated at on the day of

(Notary Signature)

(Signature of Owner Agent)

The

, a recognized chamber of commerce under the laws of the state of

, has examined the manufacturer's invoice or shipper's affidavit concerning the origin of the merchandise and, according to the best if its knowledge and belief, finds that the products named originated in the United State of North America.

Secretary

CERTIFICATE OF ORIGIN